CPR Sensitive ECG Analysis In An Automatic External Defibrillator

ABSTRACT

An automatic external defibrillator including: a sensor for detecting when a rescuer is delivering a CPR chest compression to the patient; electrodes for application to the thorax of the patient for delivering a defibrillation shock to the patient and for detecting an ECG signal; defibrillation circuitry for delivering a defibrillation shock to the electrodes; and a processor and associated memory for executing software that controls operation of the defibrillator. The software provides: ECG analysis for analyzing the ECG signal to determine if the cardiac rhythm is shockable; CPR detection for analyzing the output of the sensor to determine when a CPR chest compression has been delivered, and integration of the ECG analysis and CPR detection so that the determination of whether the cardiac rhythm is shockable is based only on time periods of the ECG signal during which there has not been a CPR chest compression delivered.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a continuation application of and claims priority toU.S. application Ser. No. 11/264,819 filed Nov. 1, 2005 which is acontinuation of Ser. No. 10/370,036, filed on Feb. 19, 2003.

TECHNICAL FIELD

This invention relates to automatic external defibrillators (AEDs), andparticularly to signal processing performed by such defibrillators.

BACKGROUND

Automated External Defibrillators include signal processing softwarethat analyzes ECG signals acquired from the victim to determine when acardiac arrhythmia such as Ventricular Fibrillation (VF) or shockableventricular tachycardia (VT) exists. Usually, these algorithms aredesigned to perform ECG analyses at specific times during the rescueevent. The first ECG analysis is usually initiated within a few secondsfollowing attachment of the defibrillation electrodes to the patient.Subsequent ECG analyses may or may not be initiated based upon theresults of the first analysis. Typically if the first analysis detects ashockable rhythm, the rescuer is advised to deliver a defibrillationshock. Following the shock delivery a second analysis is automaticallyinitiated to determine whether the defibrillation treatment wassuccessful or not (i.e. the shockable ECG rhythm has been converted to anormal or other non-shockable rhythm). If this second analysis detectsthe continuing presence of a shockable arrhythmia, the AED advises theuser to deliver a second defibrillation treatment. A third ECG analysismay then be initiated to determine whether the second shock was or wasnot effective. If a shockable rhythm persists, the rescuer is thenadvised to deliver a third defibrillation treatment.

Following the third defibrillator shock or when any of the analysesdescribed above detects a non-shockable rhythm, treatment protocolsrecommended by the American Heart Association and European ResuscitationCouncil require the rescuer to check the patient's pulse or to evaluatethe patient for signs of circulation. If no pulse or signs ofcirculation are present, the rescuer is trained to perform CPR on thevictim for a period of one or more minutes. Following this period ofcardiopulmonary resuscitation (that includes rescue breathing and chestcompressions) the AED reinitiates a series of up to three additional ECGanalyses interspersed with appropriate defibrillation treatments asdescribed above. The sequence of 3 ECG analyses/defibrillation shocksfollowed by 1-3 minutes of CPR, continues in a repetitive fashion for aslong as the AED's power is turned on and the patient is connected to theAED device. Typically, the AED provides audio prompts to inform therescuer when analyses are about to begin, what the analysis resultswere, and when to start and stop the delivery of CPR.

One limitation associated with many AEDs is that the period between eachset of ECG analyses and shocks is pre-programmed into the device and isfixed for all rescue situations. When the application of CPR due to lackof circulation is warranted, this pre-programmed period is consumed bythe delivery of rescue breaths and chest compressions. When no CPR iswarranted because the last shock was effective in converting the patientto a perfusing cardiac rhythm, this pre-programmed period is consumed byperiodically monitoring the patient's pulse and assuring that no relapseor re-fibrillation has occurred. Under some out-of-hospital rescueprotocols, the period between successive sets of ECG analyses can be aslong as 3 minutes.

It is commonly known that victims of cardiac arrest who have beensuccessfully defibrillated sometimes relapse into ventricularfibrillation shortly after a successful shock treatment. In such cases,the rescuer who verified the presence of a pulse immediately followingdefibrillation and thus decided not to perform CPR, may be unaware thatthe victim's condition has deteriorated until the next ECG analysis isperformed some 1-3 minutes later. Under these conditions, the deliveryof needed defibrillation treatments and CPR may be delayed.

Some AEDs are designed to avoid this undesirable delay in treatment bycontinuously and automatically analyzing the victim's ECG wheneverdefibrillation electrodes are connected to the patient. These AEDsperform a continuous “background” analysis that evaluates the victim'sECG signals during the 1-3 minute CPR/monitoring period betweenanalysis/shock sequences. As such, they are able to detectrefibrillation of the victim's heart (should it occur) and promptlyadvise the rescuer of the patient's deteriorated condition. While these“improved” systems help prevent the delay in treatment that can resultfrom undetected refibrillation of the patient's heart, they are alsosusceptible to misinterpreting the ECG artifact introduced by CPRrelated chest compressions as shockable arrhythmias. When the ECGanalysis algorithm misinterprets CPR related ECG artifact as a shockablerhythm, it may advise the rescuer to prematurely stop performing CPR andto deliver a defibrillation treatment. While in some cases immediatedefibrillation may be the appropriate treatment, some clinical researchsuggests that an appropriately long period of CPR between sequences ofdefibrillation treatments may be more beneficial to the patient thanimmediate defibrillation, particularly when VF has been of long durationor persistently recurring. Furthermore when the victim's cardiac rhythmis not treatable by defibrillation therapy (non-shockable) butincompatible with life such as in cases of asystole or electromechanicaldisassociation, the premature cessation of CPR in response to theerroneous detection of a shockable cardiac rhythm can reduce thepatient's chances of survival.

For those AEDs that perform background ECG analysis during periodsbetween analysis/shock sequences, a common strategy for ensuring thatsufficient time is provided for effective CPR delivery even in thepresence of shockable rhythms is to disable background ECG analysis orignore the results of this analysis for a predetermined time periodfollowing the last shock in each treatment sequence. During this period,the rescuer is allowed to perform CPR without advice from the unit thata shockable rhythm is present. Following this period, ECG analysisresults are used to prompt the user to stop CPR and thus allow a CPRartifact free ECG analysis to be performed.

Since most currently available AEDs are not equipped to detect ormonitor the delivery of CPR related chest compressions, they areincapable of determining when CPR artifact is present in the ECG signalsand when it is not. The automatic activation/deactivation of theirbackground ECG analysis function, therefore, is based exclusively upontime since the last shock or completion of the last “foreground” ECGanalysis. If the delivery of CPR is stopped during this period whenbackground ECG analyses have been disabled, life threatening changes inthe patient's ECG rhythm will remain undetected (even though it could beeffectively analyzed) for at least some period of time during the rescueevent.

SUMMARY

In general, the invention features an automatic external defibrillatorincluding: a sensor for detecting when a rescuer is delivering a CPRchest compression to the patient; electrodes for application to thechest of the patient for delivering a defibrillation shock to thepatient and for detecting an ECG signal; and defibrillation circuitryfor delivering a defibrillation shock to the electrodes. ECG analysis isperformed to determine if the cardiac rhythm is shockable (i.e.,treatable by defibrillation therapy). The output of the sensor isdetected to determine when a CPR chest compression has been delivered.The ECG analysis and CPR detection are integrated so that thedetermination of whether the cardiac rhythm is treatable bydefibrillation therapy is based only on time periods of the ECG signalduring which there has not been a CPR chest compression delivered.

The invention improves the specificity as well as the reliability of theECG rhythm classification. The improved reliability of ECG rhythmclassification (e.g. during ECG background analysis) enhances thesurvival chances of victims in at least two ways. It reduces thelikelihood of premature cessation of needed CPR as the result of a falsedetection of a shockable cardiac rhythm when the victim's cardiac rhythmis actually not treatable by defibrillation therapy (e.g., cases such asasystole or electromechanical disassociation, for which the moreappropriate therapy is CPR). It avoids undesirable delay in treatment ofre-fibrillation when it occurs, by allowing for continuously andautomatically analyzing the victim's ECG during the 1-3 minute CPRmonitoring periods between analysis/shock sequences.

Preferred implementations of the invention may incorporate one or moreof the following:

The ECG analysis may comprise analysis of the ECG signal over a minimumECG analysis time to determine whether the cardiac rhythm is shockable,and wherein integration of the ECG analysis and CPR detection may bedone so that a determination that the cardiac rhythm is shockable isonly made if the time period over which the ECG signal has been analyzedto make that determination includes a time period at least as long asthe minimum ECG analysis time during which there has not been a CPRchest compression delivered.

A timer may be reset when a CPR chest compression has been delivered,and the value of the timer may be examined to determine whether theminimum ECG analysis time has been exceeded.

The ECG analysis may be reinitialized when it is determined that a CPRchest compression has been delivered, and only after the ECG analysishas been conducted for at least the minimum ECG analysis time withoutbeing reset is a determination made as to whether the cardiac rhythm isshockable.

The ECG analysis and CPR detection may be performed continuously duringthe period in which determinations are being made as to whether thecardiac rhythm is shockable.

Other features and advantages of the invention will be apparent from thefollowing drawings and detailed description, and from the claims.

DESCRIPTION OF DRAWINGS

FIG. 1 is a block diagram of one implementation of the invention.

FIG. 2 is a block diagram of the integrating task of the implementationof FIG. 1.

FIG. 3 is a block diagram of another implementation of the invention.

FIG. 4 is a block diagram of the ECG analysis of the implementation ofFIG. 3.

FIG. 5 is a block diagram of another implementation of the invention.

FIG. 6 is a block diagram of the integrating task of the implementationof FIG. 5.

DETAILED DESCRIPTION

There are a great many different implementations of the inventionpossible, too many to possibly describe herein. Some possibleimplementations that are presently preferred are described below. Itcannot be emphasized too strongly, however, that these are descriptionsof implementations of the invention, and not descriptions of theinvention, which is not limited to the detailed implementationsdescribed in this section but is described in broader terms in theclaims.

FIG. 1 shows one preferred implementation, in which the CPR detectiontask 20 and ECG background analysis task 22 run simultaneously andcontinuously during a CPR preprogrammed interval of 1 to 3 minutes. Theoutputs of the CPR detection task (e.g., times at which CPR compressionsare delivered, amplitude of compressions, rate of compressions) and theoutputs of the ECG analysis task (e.g., times at which QRS is detected,heart rate, and rhythm classification) are passed to a higher levelintegrating task 24. The higher level integrating task analyzes the datafrom both ECG and CPR tasks and qualifies ECG rhythm classificationsbased on the presence or absence of the detection of CPR chestcompressions during the ECG analysis period. For example, if a CPR chestcompression is detected, the higher level task ignores background ECGrhythm classifications for a time interval of at least X seconds afterthe compression, where X seconds is the minimum time interval needed bythe ECG background analysis algorithm to classify an ECG rhythm. Thisguarantees that for the duration of at least X seconds the ECGbackground analysis algorithm uses a noise free ECG signal to make itsclassification. As a result, the number of false shockable rhythmdetections due to CPR related artifact in the ECG signal is reduced andthe specificity as well as the reliability of the ECG rhythmclassification is improved. This improved reliability of ECG backgroundanalysis enhances the survival chances of victims in two ways: (1) iteliminates premature cessation of needed CPR as the result of a falsedetection of a shockable cardiac rhythm when the victim's cardiac rhythmis actually not treatable by defibrillation therapy (e.g., cases such asasystole or electromechanical disassociation, for which the moreappropriate therapy is CPR); (2) it avoids undesirable delays intreatment of re-fibrillation when it occurs, by continuously andautomatically analyzing the victim's ECG during the 1-3 minute CPRmonitoring period between analysis/shock sequences and informing therescuer when a shockable rhythm has been detected.

FIG. 2 shows the process followed by the integrating task. CPRcompression detection data from the CPR task and ECG rhythmclassification data from the ECG task are received. The integrating taskchecks (30) if a compression has been detected. If a CPR compression isdetected, the integrating task sets to zero (32) the elapsed time T0since the last compression was detected and continues to execute andcheck for new compression detections. If no new compression is detected,the integrating task calculates (34) the elapsed time T0 since the lastcompression was detected. It then checks (36) to determine if T0 isgreater than the time needed (X seconds) by the ECG analysis algorithmto generate a rhythm classification. If T0 is smaller than X seconds,the integrating task returns to checking for newly detected CPRcompressions. Else if T0 is larger than X seconds, the integrating taskmoves to checking (38) the rhythm classifications being received fromthe ECG task. If a shockable rhythm is being reported, the integratingtask alerts the user to the presence of a shockable rhythm (40) andcauses the defibrillator to switch to the ECG foreground analysis state(42).

FIG. 3 shows another implementation. The CPR detection task 50 and ECGbackground analysis task 52 run simultaneously and continuously during aCPR preprogrammed interval. The outputs of the CPR task are passed tothe ECG task, and the ECG task uses the CPR data to qualify ECG rhythmclassification based on the presence or absence of the detection of CPRchest compression during the ECG analysis period. For example, if a CPRchest compression is detected, the ECG task will restart its ECG rhythmclassification process, which usually requires a predefined timeinterval of X seconds to complete its classification of rhythms. Thismethod guarantees that for the predefined time interval X seconds neededto classify a rhythm the ECG background analysis algorithm uses a noisefree ECG signal to make its classification. As a result, the number offalse shockable rhythm detections is reduced. Thus, the specificity aswell as the reliability of the ECG rhythm classification is improved.

FIG. 4 shows the process followed by the ECG background analysis task inthe implementation of FIG. 3. The ECG task receives CPR compressiondetection data from the CPR task and ECG waveform data from thedefibrillator front end simultaneously and continuously. Upon receivingan ECG waveform data sample, the ECG task checks (62) if a compressionhas been detected. If a CPR compression is detected, the ECG taskreinitializes (64) the ECG analysis by restarting it from time zero. TheECG analysis task analyzes an ECG segment of data of length X seconds todetermine the ECG rhythm. By initializing the ECG analysis process, theECG task restarts its analysis of a new ECG data segment of X secondslong resulting in no ECG rhythm classification for the next X seconds.If no new compression is detected, the ECG task checks (60) if theanalysis process has been initialized. If no ECG analysis is inprogress, the ECG task initializes (64) the ECG analysis process. If theECG analysis has been initialized, the ECG task continues to analyze theECG waveform data for duration of X seconds. If no shockable rhythm isdetected (66), the ECG task returns to receive the next sample. If ashockable rhythm is being reported (66), the ECG task switches to theECG foreground analysis state (68), and alerts (70) the user to thepresence of a shockable rhythm.

FIG. 5 shows another implementation. The CPR detection task 70 and ECGbackground analysis 72 task run simultaneously and continuously during aCPR preprogrammed interval of 1 to 3 minutes. The outputs of the CPRtask and the outputs of the ECG task are passed to a higher levelintegrating task 74. This higher level integrating task analyzes thedata from both ECG and CPR tasks, and reinitializes the ECG rhythmclassifications when a CPR chest compression is detected. The higherlevel integrating task alerts the user about a shockable rhythm whenreported by the ECG task. For example, if a CPR chest compression isdetected, the higher level integrating task will restart the ECG rhythmclassification process, which usually requires a predefined timeinterval of X seconds to a complete its classification of rhythms. Thismethod guarantees that for the predefined time interval X seconds neededto classify a rhythm the ECG background analysis algorithm uses a noisefree ECG signal to make its classification.

FIG. 6 shows the process followed by the integrating task in theimplementation of FIG. 5. The Integrating task receives CPR compressiondetection data from the CPR task and ECG rhythm classification data fromthe ECG task. The integrating task checks (80) if a compression has beendetected. If a CPR compression is detected, the integrating taskreinitializes (82) the ECG analysis by restarting it from time zero. TheECG analysis task analyzes an ECG segment of data of length X seconds todetermine the ECG rhythm. By initializing the ECG analysis process, theECG task restarts its analysis of a new ECG data segment of X secondslong resulting in no ECG rhythm classification for the next X seconds.If no new compression is detected, the integrating task checks (84) therhythm classifications being received from the ECG task. If a shockablerhythm is being reported, the integrating task alerts the user (86)about the presence of a shockable rhythm, at which point thedefibrillator switches to the ECG foreground analysis state.

Many other implementations of the invention other than those describedabove are within the invention, which is defined by the followingclaims.

1. An automatic external defibrillator for delivering defibrillationshocks to a patient, comprising a sensor for detecting when a rescuer isdelivering a CPR chest compression to the patient; electrodes forapplication to the thorax of the patient for delivering a defibrillationshock to the patient and for detecting an ECG signal; defibrillationcircuitry for delivering a defibrillation shock to the electrodes; aprocessor and associated memory for executing software that controlsoperation of the defibrillator, the software providing ECG analysis foranalyzing the ECG signal to determine if the cardiac rhythm is shockable(treatable by defibrillation therapy); CPR detection for analyzing theoutput of the sensor to determine when a CPR chest compression has beendelivered, and integration of the ECG analysis and CPR detection so thatthe determination of whether the cardiac rhythm is shockable is basedonly on time periods of the ECG signal during which there has not been aCPR chest compression delivered.
 2. The defibrillator of claim 1 whereinthe ECG analysis comprises analysis of the ECG signal over a minimum ECGanalysis time to determine whether the cardiac rhythm is shockable, andwherein integration of the ECG analysis and CPR detection is done sothat a determination that the cardiac rhythm is shockable is only madeif the time period over which the ECG signal has been analyzed to makethat determination includes a time period at least as long as theminimum ECG analysis time during which there has not been a CPR chestcompression delivered.
 3. The defibrillator of claim 2 wherein a timeris reset when a CPR chest compression has been delivered, and the valueof the timer is examined by the software to determine whether theminimum ECG analysis time has been exceeded.
 4. The defibrillator ofclaim 3 wherein the ECG analysis is reinitialized when the softwaredetermines that a CPR chest compression has been delivered, and onlyafter the ECG analysis has been conducted for at least the minimum ECGanalysis time without being reset does the software make a determinationas to whether the cardiac rhythm is shockable.
 5. The defibrillator ofclaim 4 wherein the ECG analysis and CPR detection are performedcontinuously during the period in which determinations are being made asto whether the cardiac rhythm is shockable.
 6. An automatic externaldefibrillator for delivering defibrillation shocks to a patient,comprising a sensor for detecting when a rescuer is delivering a CPRchest compression to the patient; electrodes for application to thechest of the patient for delivering a defibrillation shock to thepatient and for detecting an ECG signal; defibrillation circuitry fordelivering a defibrillation shock to the electrodes; ECG analysis meansfor analyzing the ECG signal to determine if the cardiac rhythm isshockable (treatable by defibrillation therapy); CPR detection means foranalyzing the output of the sensor to determine when a CPR chestcompression has been delivered, and integration means for integratingthe ECG analysis and CPR detection so that the determination of whetherthe cardiac rhythm is shockable is based only on time periods of the ECGsignal during which there has not been a CPR chest compressiondelivered.
 7. The defibrillator of claim 6 wherein the ECG analysisincludes analysis of the ECG signal over a minimum ECG analysis time todetermine whether the cardiac rhythm is shockable, and whereinintegration of the ECG analysis and CPR detection is done so that adetermination that the cardiac rhythm is shockable is only made if thetime period over which the ECG signal has been analyzed to make thatdetermination includes a time period at least as long as the minimum ECGanalysis time during which there has not been a CPR chest compressiondelivered.
 8. The defibrillator of claim 7 wherein a timer is reset whena CPR chest compression has been delivered, and the value of the timeris examined to determine whether the minimum ECG analysis time has beenexceeded.
 9. The defibrillator of claim 8 wherein the ECG analysis isreinitialized when it is determined that a CPR chest compression hasbeen delivered, and only after the ECG analysis has been conducted forat least the minimum ECG analysis time without being reset is adetermination made as to whether the cardiac rhythm is shockable. 10.The defibrillator of claim 9 wherein the ECG analysis and CPR detectionare performed continuously during the period in which determinations arebeing made as to whether the cardiac rhythm is shockable.
 11. A methodfor automatically delivering defibrillation shocks to a patient,comprising applying electrodes to the chest of the patient fordelivering a defibrillation shock to the patient and for detecting anECG signal; using a sensor to detect when a rescuer is delivering a CPRchest compression to the patient; analyzing the ECG signal to determineif the cardiac rhythm is shockable (treatable by defibrillationtherapy); analyzing the output of the sensor to determine when a CPRchest compression has been delivered, and integrating the ECG analysisand CPR detection so that the determination of whether the cardiacrhythm is shockable is based only on time periods of the ECG signalduring which there has not been a CPR chest compression delivered. 12.The method of claim 11 wherein the ECG analysis includes analysis of theECG signal over a minimum ECG analysis time to determine whether thecardiac rhythm is shockable, and wherein integration of the ECG analysisand CPR detection is done so that a determination that the cardiacrhythm is shockable is only made if the time period over which the ECGsignal has been analyzed to make that determination includes a timeperiod at least as long as the minimum ECG analysis time during whichthere has not been a CPR chest compression delivered.
 13. The method ofclaim 12 wherein a timer is reset when a CPR chest compression has beendelivered, and the value of the timer is examined to determine whetherthe minimum ECG analysis time has been exceeded.
 14. The method of claim13 wherein the ECG analysis is reinitialized when it is determined thata CPR chest compression has been delivered, and only after the ECGanalysis has been conducted for at least the minimum ECG analysis timewithout being reset is a determination made as to whether the cardiacrhythm is shockable.
 15. The method of claim 14 wherein the ECG analysisand CPR detection are performed continuously during the period in whichdeterminations are being made as to whether the cardiac rhythm isshockable.